Methods

In February 2011, EthnoMed staff and two University of Washington students conducted two focus groups with a total of eight refugees from Iraq who had at that time been in the Seattle area from between 3 weeks to 3 years. The groups were evenly divided between men and women. Participants were all adults, mostly of working and parenting ages in their 30s and 40s, with a few participants in their 20s and 50s. Most came from urban areas of Iraq. Each group had an interpreter, also a refugee from Iraq, who was invited to participate in the discussion.

Interviews were conducted with three resettlement coordinators from a local VOLAG (voluntary resettlement agency) and a mental health professional from a social service agency serving refugees.

Published literature was reviewed and incorporated where indicated.

Additions specific to Iraqi health, history and culture were provided by Iraqi American physicians Muna Al Khalidi, A. Hadi Al Khalili, Donna Denno, and Nuhad Dinno during the process of reviewing this article.

Introduction

To date, little has been written about the American health care experience of Iraqi refugees who have arrived since the U.S.-led invasion of Iraq in 2003. Written and anecdotal reports suggest that relative to other recent refugee groups, the Iraqis are having a significantly more difficult time establishing their lives in the U.S. In fact, the International Rescue Committee (IRC) and other organizations have described the resettlement situation as a crisis.

Despite the hardships, most Iraqi refugees are grateful to be here, to be safe, and to enjoy the freedoms of the U.S.

This cultural profile provides information about the American health care experiences of a small group of Iraqi refugees in the Seattle area and health-related beliefs and expectations they understand to be common in their community; the health care system in Iraq; historical context pertinent to the physical and psychological needs of recent refugees; and refugee resettlement in the United States.

Who Are The Refugees?

In 2010, the United Nations High Commissioner on Refugees (UNHCR) reported that since 2003, over four million Iraqis (1 in 6) have been displaced, with 2 million having fled to other countries and 2.7 million being internally displaced. The majority of Iraqis who have fled are living in Syria and Jordan, but others are in Egypt, Lebanon, Turkey, Sweden, Canada and the United States. This is the largest exodus since the mass migrations associated with the creation of the state of Israel in 1948 (The New York Times, 2011).

Al-Askari Mosque before the bombing in 2006.

Iraqi Refugees in the United States

Increasingly Iraqis have been immigrating to the U.S. since the 1990 Gulf War. In 2003, the U.S. invasion of Iraq contributed to escalating violence and unrest in the country. A refugee crisis began in February 2006 with the alleged al-Qaida bombing of the al-Askari mosque in Samarra, Iraq— one of Shiite Islam’s holiest sites. It is presumed that this attack was intended to incite sectarian violence between Shiites and Sunnis. Though no one died in the bombing, widespread violence erupted throughout Iraq. Dozens of mosques were attacked, hundreds died, and millions of Iraqis fled their homes. Many fled to Jordan and Syria and others relocated within Iraq.

In 2008, there was a large increase in the number of Iraqis arriving to the U.S. primarily due to the passage of the Refugee Crisis in Iraq Act which provides up to 5,000 special immigrant visas (SIVs) yearly for Iraqis who worked with the United States and protection or immediate removal from Iraq of SIV applicants who were in imminent danger. This method of access to the U.S. requires a high level officer referral, and has mostly been used for former military interpreters. Iraqis who are granted SIVs come with a green card rather than traditional refugee status, but they are eligible for refugee services.

There are three traditional categories of refugee cases, or methods of refugee access to the United States, managed by the U.S. Refugee Program:

Priority One (P1) is reserved for individuals, referred to the program by UNHCR, a U.S. Embassy, or a non-governmental organization (NGO), who are refugees facing compelling security concerns in countries of first asylum, needing legal protection because of the danger of forced return, or facing danger due to threats of armed attack. It also includes former political prisoners, women at risk, victims of torture or violence, physically or mentally disabled persons, persons in urgent need of medical treatment, and persons for whom other durable solutions are not feasible and whose status in the place of asylum does not offer a satisfactory long-term solution. Many of the Iraqi refugee P1 cases are medical in nature.

Priority Two (P2) is used for designated groups of special humanitarian concern to the United States. It includes specific groups (within certain nationalities, clans, or ethnic groups) identified by the Department of State in consultation with U.S. Citizenship and Immigration Services, nongovernmental organizations (NGOs), UNHCR, and other experts. P-2 cases represent the largest number of refugees resettled. Many Iraqis who were closely associated with the U.S. in Iraq are now being processed as P-2s.

Priority Three (P3) is for family reunification for designated nationalities. This priority category is currently not in use.

The table below shows the total number of Iraqi refugees that have arrived since 2006 (this includes refugees arriving via SIV & via traditional UNHCR pathways).

Table: Iraqi Refugees to the United States

FISCAL YEAR

2006

2007

2008

2009

2010

Jan - March

2011

NUMBER OF

IRAQI REFUGEES TO U.S.

183

1,608

13,822

18, 838

18,016

2,104

Source: Department of State, Bureau of Population, Refugees and Migration, Refugee Admissions Report as of March 31, 2011.

Iraqi Refugees are a Diverse Group

Refugees from Iraq are a very diverse group. They come from many faiths and backgrounds. Sectarian violence and persecution have affected different groups for different reasons.

According to the CIA’s online World Factbook, Iraq’s population in 2008 was about 28 million, of whom 75% to 80% are Arabs and 15% to 20% are Kurds, with smaller numbers of Armenians, Assyrians, and Turkomen. Islam is the predominant religion, practiced by 97% of the population. Of Iraqi Muslims, 60% to 65% are Shi’i Arabs and 32% to 37% are Sunni Arabs or Kurds. A small number of Iraqis, including Ali-Ilahis and Yazidis, are syncretic Muslims. Christians make up 3% of the population: Armenians, Assyrians, and Chaldeans are all Christians, and there are also some Arab Christians. Arabic, the national language, is spoken with some level of proficiency by all Iraqis (Ghareeb, Ranard, & Tutunji, 2008). Non-Arabs, in addition, speak their own ethnic languages.

Over the past 30 years, Iraq has hosted, with UNHCR assistance, Palestinian, Iranian, Turkish and Syrian refugees. When Sadaam Hussein’s regime collapsed, so did the entire support network for refugees in central and southern Iraq. Many found that once-friendly host communities had turned hostile and some were forced to leave their homes (United Nations High Commissioner for Refugees, 2011).

For Muslims in Iraq, widespread sectarian violence is the most common reason for flight. Members of non-Muslim minorities, including Baha’is, Christians, Jews, Sabaean-Mandaeans, and Yazidis have increasingly become targeted for religious reasons or because of their ethnicity, or even at times because of socio-economic motivations. For example, one refugee described to a Seattle-area health care provider how members of his community, historically prosperous silversmiths, goldsmiths and jewelers by trade in Iraq, have been targeted for kidnapping – often repeatedly – for ransom. Kidnapping for ransom or other reasons has become rampant in Iraq.

Still other Iraqis have suffered persecution for political reasons. They are supporters, or perceived to be supporters of the former regime, the insurgency, the current Iraqi government, or the multinational forces. Also at risk are those who are perceived to be traitors to the country of Iraq by having worked with the American armed forces, American government agencies, companies or aid groups. People who are accused of un-Islamic behavior, as well as members of certain professions, such as doctors, journalists, actors, and artists, have also been targeted. Women in Iraq – particularly female heads of households or single women without male protection – also form a vulnerable target for militias, insurgents, Islamic extremists, and family members seeking to commit honor killings (a growing practice in Iraq, one in which a woman believed to have shamed the family in some way is killed) (Ghareeb, Ranard, & Tutunji, 2008).

For more information about Iraq’s history, culture, ethnic and religious communities, and languages see the Cultural Orientation Resource Center’s Enhanced Refugee Backgrounder: Refugees from Iraq.

Iraqi Refugees “In Dire Straits”

According to many organizations that provide support for the refugees throughout the U.S., their adjustment has been particularly difficult. The International Rescue Committee has described the situation as a crisis in their 2009 report, Iraqi Refugees in the United States: In Dire Straits.

Factors contributing to this crisis are complex. Major factors include:

Financial stress due to difficulty finding employment during the U.S. recession, paired with refugee benefits that have not been increased to accommodate longer periods of unemployment.

English language learning needs that are high and programs that are not adequate to meet the need.

High physical and mental health needs.

Loss of identity and adjustment to lower standard of living. This adjustment is often coupled with a sense of entitlement, particularly for those forced to flee their homes because of ties to the U.S.

In preparation for writing this profile, the authors encountered many newspaper articles from all over the U.S. written in the past 3 years about local Iraqi refugees and their significant economic and personal struggles.

In-depth discussion of contributing factors follows.

Refugee Resettlement Program Needs Overhaul

The U.S. refugee resettlement assistance system has undergone little reform in the 30 years since Southeast Asian refugees were resettled after the Vietnam War. The program was premised on refugees being able to obtain employment and become self-supporting shortly after arrival to the U.S. The economic recession has hampered refugees’ ability to be self-sufficient quickly.

There is broad consensus that refugee benefits are not adequate and terminate too quickly to accommodate a recession with high unemployment rates. Nationwide, unemployment for refugees is estimated to be significantly higher than the general public. Washington’s refugee employment rate ranked near the bottom at 46 out of all 50 states (Office of Refugee Resettlement, 2009). In 2009, only 28% of Washington State’s employable refugees were employed and only 13% of those jobs came with benefits. The average wage is $9.41 an hour. This average wage is significantly below the “housing wage.” According to the National Low Income Housing Coalition, a wage of $15.48 an hour is needed in Washington State to be able to afford a one-bedroom apartment at fair market rent; $18.46 is required for a two-bedroom apartment (National Low Income Housing Coalition, 2011). Some refugees in Washington State are at risk for homelessness. A Georgetown University report on Iraqi refugees in the United States, which is based on interviews with refugees, refugee caseworkers, policy makers, government and non-profit organizations, asserts that the U.S. has not devoted enough attention to breaking down key barriers to employment for refugees. Employment services provided by VOLAGS (voluntary agencies) and state agencies are underfunded, which impacts their ability to serve clients. Transportation barriers in many locations add to challenges in finding and maintaining employment and attending English classes. English classes may not be long enough or of adequate quality. In Washington State, recent budget cuts have reduced money available for ESL programs. Locally and nationally, re-certification programs are unavailable or difficult to attend due to pressing economic needs. The vast majority of Iraqi refugees interviewed for the Georgetown University report were unemployed, though they had a strong desire to work (Georgetown University, 2009).

Increases to cash benefits for refugees in light of the economic recession have not been made. In fact, in February 2011, refugees in Washington State experienced a 15% cut to monthly benefits. A single person used to receive $359 a month, which has been reduced to $305. This amount is intended to cover all living expenses, except for food, which is covered by food stamps. Benefits last for 8 months for people without minor children. Those with minor children receive benefits for 5 years. Medical benefits, provided under the Medicaid program, are also subject to these time limits.

Larger families particularly struggle. Single persons often have less of a financial burden due to higher per capita benefit levels. A cross-section of Iraqi refugee clients in the Seattle area are cases of families of 3, 4, and 5 people who are afforded $478, $562, and $648 in cash benefits, respectively. While single persons can share housing with others in the community, families have fewer options. Refugees also receive a one-time cash award of $1100 per capita from the government upon entry. This money is administered by VOLAGS and is intended to help people get on their feet.

According to the refugees interviewed for this article, refugee health benefits are not adequate. “The health benefits should go longer than eight months for singles and longer for the families.”

In Washington State some medical benefits were cut for refugees in 2011. Refugees 21 years of age and older no longer receive prescription, dental, vision hardware, hearing exams, and podiatry benefits. State-funded interpreter services were cut in March 2011.

According to the IRC report on Iraqi refugees,the severity of the financial situation has been so dire that some refugees have received money from relatives in Iraq to help cover basic needs such as housing. Some have even returned to Iraq, which continues to be unstable and unsafe for this group.

The U.S. National Security Council is leading a multiagency task force looking to reform refugee resettlement in America. A number of reports submitted to the Council about the shortcomings of the system have focused on the recent experience of Iraqi refugees in the United States (Congressional Research Service, 2011).

Iraqi Refugees are a Unique Group

The service providers with whom the authors spoke have described Iraqi refugees as a unique group.

They have the highest PTSD and physical injury rates of any group resettled in our area in recent history. The economic stresses they face are enormous, having arrived when unemployment rates are high. Many are unable to find work, even in low-paying positions. Some Iraqis with strong professional backgrounds refuse to accept low-paying positions or, as such, may be reluctant to take the first job available. Some who apply for entry level jobs are rejected because they are considered over qualified. Many Iraqis have not been adequately counseled before arrival about the economic situation in the United States and are shocked to be struggling to survive after arrival. According to one resettlement coordinator, some Iraqis are comforted to know that so many Americans are struggling too, to find employment, and that it is “not just them.” She advises, “I have found that employment statistics or even economic discussions can be very helpful with this group in particular.

The recent Iraqi refugees never lived in refugee camps. They come with relatively more education than adults coming from camp backgrounds. Quite a few were well-educated and well-paid professionals in Iraq. Prior to the Gulf War, the professional class had a high standard of living, including good health care. The change in standard of living in the U.S. has been a big adjustment for Iraqis.

Most Iraqis who are professionals do not have their credentials recognized here. The availability of recertification programs is limited, depending on the field. The recertification process can be expensive, so those working minimum wage jobs may not be able to afford recertification for years, if ever. Those who do not speak English will have to master the language first. Even those with good English skills may not be proficient in the terminology of their profession.

Unlike many other refugee communities, recently arrived Iraqis typically find less support and guidance from more established community members. Iraqi society primarily orients around family. There is great diversity among Iraqis, including social class, religion, and political affiliations, and in Iraq, social relations outside the family are heavily influenced by such distinctions and status. This norm prevails in the U.S. as well, with some refugees being less willing to socialize or even to interact with people of different classes or backgrounds. Because of the war, Iraqis may feel a further lack of trust for each other or may even be afraid of each other. For example, some individuals who worked with the U.S. as interpreters in Iraq may be perceived as traitors by other people in the refugee community here.

Finally, many refugees continue to have grave concerns about the safety of family and friends who remain in Iraq and face ongoing trauma as a result.

High Physical Health Needs

Iraqi refugees arrive with high rates of trauma, injury, and illness. The situation is complex. Those who have been victims of torture and violence may come with wounds, amputations, and traumatic brain injury. Others may arrive with a large number of physical complaints that require an extensive workup, some of which are untreated medical conditions that have led to greater complications. Some may manifest symptoms which are due to stress or PTSD.

An American physician who cares for many Iraqi refugees shared the following information: “Many patients come in with a litany of physical complaints such as headache, backache, etc. For patients whose benefits end in eight months, providers are up against a tight window to do a legitimate workup.” He observed that some refugee patients in his practice appear to feel so incapacitated by their health that they do not feel they can work and want to apply for SSI. At the same time, a doctor or caseworker could understand that the level of disability diagnosed for a given patient would not qualify for SSI coverage. A mental health professional interviewed for this article commented that disabilities not meeting SSI criteria in the U.S. may still be considered serious enough debilitations from the patients’ perspectives, especially if the condition would have made them unable to work in Iraq. In numerous cases, mental health issues such as PTSD may be underlying the physical health issues, and patients with stress-related illness may resist mental health services due to cultural stigma. The physician quoted above described other patients with no apparent illness or disability who also want to apply for SSI, leaving him to wonder what underlies these requests. The Iraqi American physicians who reviewed this article suggest that among some refugees, there may be feelings or perceptions of entitlement to services because of the U.S. involvement in Iraq that precipitated devastating experiences and displacement. The reviewers also noted that there are those people who may feel too proud to go on SSI or depend upon government services. The American physician expressed frustration, “My colleagues and I feel that we are not meeting the needs of this group [Iraqi refugees]. We’re looking for ways to help them.”

According to a study by the CDC based on refugee screening done in California, Iraqi refugees newly arrived in the United States are exhibiting high rates of chronic health conditions, including obesity rates at the same levels as Californians. More than 15 percent of Iraqi adults were diagnosed with high blood pressure, and almost 40 percent of those 40 years or older had high cholesterol levels (Reuters, msnbc.com, December 17, 2010). Consistent with research in California, a review of health information from refugees in southern Connecticut found that among the recent wave of refugees from Iraq, 57% of adults had been treated for or diagnosed with at least one chronic health problem during that time (Yun, Hebrank, Graber, Sullivan, Chen, & Gupta, 2012).

Increasing number of congenital anomalies and cancer-related deaths among both adults and children in Iraq, linked by specialists to the use of war weapons from the Gulf War; unsafe products in agriculture; and the long-term effects of war on the population’s resistance to disease (Macpherson, 2010; Simpson, 2010);

High rates of latent TB among refugees. According to a CDC study, Iraqis resettled in San Diego County, California between October 2007 and September 2009 registered high rates of latent tuberculosis infection among their elderly, found in over half and comparable to those in refugee groups from other countries. The prevalence of culture-confirmed TB cases among all new Iraqi refugees was much lower than those in recently resettled populations from other countries. Prevalence of chronic hepatitis infection was also lower among Iraqi refugees than for other recently resettled populations (Centers for Disease Control and Prevention, 2010).

High Mental Health Needs and Stigma Associated with Services

One in five Iraqi refugees has been tortured or has experienced other violence, according to data collected by United Nations in Syria (Amos, D., NPR, January 17, 2008). Many others have witnessed torture, violence and killings of friends and loved ones. Many are war-widows, arriving in the U.S. grieving and with sole responsibility for their children. Many continue to worry about the safety of friends and loved ones in Iraq.

The data collected by the U.N. in Syria is based on interviews with 754 refugees. Results revealed that 89.5% are suffering from depression, 81.6% from anxiety, and 67.6% from post-traumatic stress disorder (PTSD). According to the survey, 77% of respondents had experienced air bombardments, shelling, or rocket attacks; 80% had witnessed a shooting; 68% had undergone interrogation or harassment by militias; and 75% knew someone close to them who had been killed.

A Seattle-area mental health provider who works with refugees shared the following:

Over 30% of the refugees in our area screen positive for depression or anxiety. The rate is much higher in the Iraqi community due to high rates of trauma and injury. Rates of PTSD among Iraqi refugees in the Seattle area are estimated to be around 51% (estimated to be 33% for non-Iraqi refugees). This provider said that she has never seen such widespread PTSD in any other group with whom she has worked. Colleagues who have been in the field longer than she say that the same high rates of PTSD were observed among Cambodian and Hmong refugees. She also mentioned that among the small number of Iraqi refugee clients from the 1990 Gulf War served by her agency, depression is the predominant diagnosis. With the more recent group, PTSD predominates.

She has observed a trend among her agency’s clients who worked for the American armed forces. They are less likely to admit to PTSD due to “more of a tough military mentality.” Some husbands seek help for their wives and will then use their psychotropic medications. Some men will bring their wives for counseling and after the wife’s session, will linger and talk to the counselor.

It is critical for American providers to know that “mental health” is a loaded term for Iraqis. The mental health system in Iraq consists primarily of psychiatric hospitals where you go if you have a chronic and severe mental illness like schizophrenia. In Iraq, having such a mental illness is still highly stigmatized as it is in many countries. Iraqi psychiatric hospitals are grim places where patients may never leave. Therefore, people have no real concept beyond the hospitals; so they would not want to have anything to do with something that could lead them to be committed to such a place. Some Iraqis worry that psychiatric hospitals are where political dissidents are sent. This fear may stem from having lived in an informant society or in a society without a strong, protected confidentiality in medical care. See CCN article Doctors work to rescue patients in Iraq’s mental health system.

In Iraq, psychiatric services are documented in medical records and this has sometimes been used to limit full participation in society by affecting employment or being used against the person by the government.

Some Iraqis experience a high number of somatic complaints that are characteristic of PTSD. When working with Iraqis, it is important to avoid using the term “mental health.” One alternative is to use symptoms rather than jargon. For example, “You are having trouble sleeping at night and you cry every day.” Rather than, “You seem depressed.” Or, “You have bad nightmares and think about what happened to you all the time.” Instead of, “You have PTSD.” Then talk about the treatment plan in terms of how it might alleviate symptoms.

If it is not possible to avoid saying “mental health,” the following explanation is suggested: “'Mental health' in the United States means something different than in many parts of the world. I know in many places 'mental health' means the same as 'crazy.' Here, mental health refers to a range of symptoms from not sleeping well, to having nightmares, to feeling like there are too many thoughts racing in your head, to crying a lot. Because refugees have been through so many bad things, and because adjusting to life in the U.S. is hard, sometimes they need extra support. That is what we do here. This is why we would like to refer you to____. We try to find out what is happening in your life and how we can help."

It may help in building trust and understanding with patients to spend significant time talking about confidentiality. Give examples: “That means that I cannot tell people what you told me without you saying it is OK, or I will get in trouble. The interpreter cannot say what you told him or he could get fired."

If a physician refers the patient for counseling, it is recommended that the physician’s office make the referral instead of simply giving the contact information to the patient. This will increase the likelihood that the patient will go to an appointment.

The biggest stressor for this group is lack of economic resources. This may be due to unemployment, or the inability to pay rent even when on cash assistance or disability. Unless a person is in immediate psychological distress, some clinicians may delay beginning counseling until the refugee becomes more settled, as practically speaking, it is necessary to deal with the immediate needs of getting established in a new country such as shelter, employment, getting children enrolled and settled in school, etc. The scarcity of jobs for refugees contributes to protracting the adjustment period.

Adult refugees coming into Washington State get 8 months of Medicaid which covers mental health care and medical care (not all states provide this same coverage). Often, people need more than 8 months of treatment. If someone’s medical coupon expires – which many do at 8 months – then treatment is in jeopardy due to lack of funding.

Refugees who have been prioritized for resettlement due to their medical need may find it difficult to get approved for disability (SSI) in the United States. The situation is even more challenging if a refugee does not bring medical records from his/her home country providing documentation about the disability. In this case, it takes time to see specialists and build up a body of medical evidence. Refugee benefits will likely end before approval for SSI is determined. Depending on the location, refugees may be able to receive Medicaid while waiting for a determination.

Additional stressors on Iraqi refugees include changing marriage and family dynamics. Especially if both partners are working, there may be a loss of identity for men in particular due to change in economic situation and employment in a low-skilled job.

In Iraq, most parents use some physical discipline raising their children. Once in the U.S., kids may be told at school to call 911 if their parents hit them. Iraqi parents may not be aware of alternative discipline approaches that might be considered more acceptable. At a community meeting, Iraqi parents said they think the message for kids here needs also to be one that encourages respecting and listening to parents.

For many refugee groups the concept of day care is completely unfamiliar and therefore, couples may feel concerned about putting their children in the care of strangers.

Navigating our Complex Health Care System

Common stressors are understanding and navigating our health care system, communicating with American providers, and obtaining health care when refugee benefits end. For more information, see Experience with Health Care in the U.S. below.

Loss of Identity

Most Iraqi refugees experience a dramatic drop in their standard of living and social status. There is a crisis of identity. Those who are fortunate to find jobs usually find themselves in positions that do not use their education or skills.

Issues Related to Health Care: Focus Groups Narrative

Unless otherwise noted, information in this section was obtained from focus groups as described in the Methods section above.

Health Care in Iraq

Health and Humanitarian Crisis Post-Gulf War (1991)

Iraqis acknowledge a general decline in the quality of health care – which was previously highly functioning – around the time of the Gulf War. This included the introduction of new illnesses, such as chicken pox, measles, and cholera that were formerly not concerns. War weapons from the Gulf War are seen as a causal factor in the rising incidence of cancer. The cost of medicine rose as a consequence of the conflict. Sanctions limited the imports of chemicals and equipment needed to purify Iraq’s water supply. As medicine became more expensive to make, the quality declined. This led some Iraqis to turn to herbal medicine.

A review of information found in news sources supports statements made about the rising incidence of cancer and birth defects correlated with exposure to radiation leaked by fallen depleted-uranium shells. These weapons were used in during the Gulf War in 1991 and after the invasion in 2003 and have contaminated the ground and water sources.

In May 2008, the American Institute of Medicine/National Academy of Sciences held an Iraq Health symposium to encourage rebuilding health services in Iraq. Their executive summary describes how every aspect of Iraq’s health system is under serious strain:

Iraq’s health system is suffering from decades of conflict, mismanagement and sanctions, as well as the effects of the ongoing insurgency and sectarian influence. Iraq has some of the poorest health indicators both in the region and in the world. The lingering effects of decades of war and UN sanctions, the ongoing insurgency, and the inability of the Iraq government to adequately remedy health issues create dire circumstances for Iraq’s health system. Every aspect of Iraq’s health system is under serious strain. This is reflected in Iraq’s dismal health indicators, which continue to be among the worst in the region; although there are signs of improvement. Iraq faces a unique ‘triple burden’ of disease; with prevalent acute respiratory and diarrheal infectious diseases typical of a developing country and a high incidence of chronic disease such as cancer, diabetes, and cardiovascular disease typical of a developed country, coupled with the ongoing emergency care, trauma, and mental health burden created by the insurgency. These challenges are made all the more difficult in light of the exodus of large numbers of Iraqi health professionals due to threats of violence (Institute of Medicine/National Academy of Sciences, 2008).

Photo credit: U.S. Air Force by Tech. Sgt. Andrew M. Rodier. Licensed under Creative Commons Attribution 2.0 http://creativecommons.org/licenses/by/2.0/deed.en. Local children line up in front of Al-Tasmeem primary school in Baghdad, Iraq, Sept. 29, 2007, to receive soccer balls donated by U.S. Army Pfc. Nick Madaras.

Children’s Health Crisis

In some regions, up to 90% of children are not attending school. A 2006 UNICEF-supported survey showed that 21% of Iraq’s children were malnourished, including 8% underweight (<2 standard deviations for weight for age), and 4% wasted (<2 standard deviations for height for weight) (UNICEF, 2007).

The child mortality rate among Iraqi children rose dramatically during the U.N. sanctions which lasted from August 1990 to May 2003. Most sources report a rate of 1 in 8 children dying before their fifth birthday in the year 2003. Reports of current rates vary, ranging from 1 in 20 to 1 in 43.

Iraq’s Health Care System

Before the year 2000, Iraq’s health care system was regarded as perhaps the best health care system in the Arab Middle East. Even in the 1990s when much of Iraq was struggling under UN-imposed sanctions, people would continue to come from across the region to study medicine and receive treatment (Dean, 2010).

Before 1990, there was general access to free health care for everyone in Iraq. Public health services (e.g., epidemic disease control, sanitation and clean water) were well established; emergency services included ambulance transportation and patients had access to secondary and tertiary care; and, sufficient medicine, medical supplies and equipment were provided to health facilities. In the cities, hospitals were teaching facilities staffed by physicians from the universities. Many physicians also had private practices outside the hospitals where they would work in the afternoon.

In Iraq’s health care system, government hospitals and private clinics are the primary locations where people seek medical care.

The private clinic system provides a higher level of service for a higher price than the government hospitals. Both government and private facilities historically had doctors that were highly specialized. In Iraq, most adults do not seek to establish regular care from a single primary care provider, general practitioner or family doctor, though some do (see section on Private Clinics below). Instead, individuals select the doctor based on their own symptoms or the types of treatment sought. Referrals to specialists are not required in Iraq’s health care system and a variety of specialists work in the same location. This arrangement significantly reduces the time between appointments and any necessary testing. Testing is done in the same location and results are received the same day.

Private Clinics

Private clinics are often preferred because of the opportunity to personally select a doctor for continuity of care. Many Iraqis tell friends and family which doctors they consider the best, so “for a really good doctor it is difficult to get in because many people want to visit the same doctor.” This makes appointments necessary. The lack of referral system also contributes to the popularity of some doctors who become well known and respected by the community.

Government Hospitals

Doctors at general hospitals work unpredictable schedules, making it unlikely an individual will continue to see the same doctor over time. For primary care, patients will usually walk-in [versus making appointment] and expect a two- to three-hour wait because of the lower cost associated with government facilities. This walk-in system is seen by many as an advantage especially when the need is urgent, instead of having to wait several days for an appointment as is common in the U.S. For specialty care, however, an appointment is generally necessary and obtained through a referral.

Some Iraqis in the focus groups noted instances of poor treatment at the hospitals in Iraq. Some medical providers at government hospitals were described as apathetic when avoidable mistakes were made or wrong prescriptions were given. This leads to frustration, as “people die through these mistakes and nobody cares.” (The Iraqi American physicians who reviewed this article suggested that poor outcomes are likely the result of lack of diagnostics and medicines resulting in poor case management, as well as a shortage of health care personnel. For example, there is a lack of supervision due to shortage of senior physicians.) One focus group participant spoke about experiences with “fake doctors” working in the hospitals. Since 1991 there has been an exodus of Iraqi professionals in all fields, including medicine, due to threats of violence, making the system vulnerable to charlatans. Sadly, some physicians have been assassinated in Iraq.

The Medical Appointment

When interacting with a patient, a doctor in Iraq would usually provide treatment options, clarifying how much each option costs. This is important because “sometimes people don’t have much money and would choose [the] cheapest option.” The Iraqi American physicians who reviewed this article add that some patients have a preference for the type of medication they receive, such as oral versus injection. Some patients will discard medication if they find it inconvenient to use, even before trying.

It is typical for a male to accompany a woman to appointments or procedures, particularly if the doctor is male. According to one man, this is “to prevent any look that might hurt the female. This is part of Oriental society. We trust the doctor, but it is part of our tradition. I trust the doctor, but she is my wife.” In general, men prefer male doctors and women prefer females, though this is highly dependent on the individual.

Corruption

There is concern about corruption in the medical system in Iraq, with “concern that there is corruption between the lab doctor and the doctor, and the doctor takes a cut.” Some Iraqis worry that corruption influences the treatment or medicines prescribed. In one case, one man explained, “I had to pay a bribe to get the medicine for my mom” when seeking medical care at a government facility. Reviewers of this article clarified that corruption is a relatively new problem and likely the result of U.N. sanctions imposed in 1990 which caused a vast shortage of medications and medical supplies.

Role of Pharmacy in Treatment for Acute Illnesses

Pharmacist Abd-Al Jabar Khani prepares a prescription at Al-Arafa Clinic pharmacy, Kirkuk, Northern Iraq, 2003. This is one of the four clinics in Kirkuk renovated through a grant by International Medical Corps.

Prescriptions are needed for “dangerous medicines” or for medications for chronic illnesses. Antibiotics and medications for acute illnesses such as the flu or headaches can be bought directly from the pharmacy without seeing a doctor first (for more information about antibiotic use, see Antibiotics below). This is appreciated when an individual “is infected with the same disease they have had before and know which medication is needed.” Some injections are available for pick up at the pharmacy without a prescription. This is fairly common but is often dependent on a friend or family member’s ability to administer the injection. One participant spoke about commonly purchasing injections of “analgesic” at the pharmacy to treat a fever. Many view this easy access to medication as an advantage since it allows people to avoid a visit to the doctor. There is a general sense of personal responsibility, as “for small problems, you can go to the pharmacist and solve it and that’s it. Try to be reasonable about things you can fix yourself.”

Medication Use

People often “listen to their friends about what medicines are good” and will share medications for simple or mild illnesses, but not serious ones. Some doctors more readily prescribe medicine, while others are more hesitant. The completion of a prescribed treatment is dependent on the individual and on the advice of the doctor. Some will finish the complete treatment while others will stop when they begin to feel better.

Women’s Health

Gynecological Care

Most Iraqi women will find a good gynecologist and return to the same one over time. A female doctor is generally preferred.

Pap Screening and Mammograms

Pap tests and mammograms are available in Iraq; but, they are not done as part of routine screening. A woman will not seek preventive screening tests such as pap smears or mammograms, unless she has reason for concern (see section on Preventive Care below).

Birth Control

The Iraqi American physicians who reviewed this article report that birth control pills can be bought from the pharmacy in Iraq without a prescription after consulting with the pharmacist about which type is best. A woman may get a recommendation from a friend about a particular type of pill and will then go to the pharmacy to purchase that kind. Some women will first consult with their doctors and this discussion is seen by many to be acceptable because “it is science.”

Pregnancy

Typically, an Iraqi woman will make an appointment with her doctor when she first discovers her pregnancy. She usually visits her primary care physician or obstetrician monthly during the first and second trimester of her pregnancy. During the seventh and eighth months, she will see the doctor twice a month and then weekly in the ninth month.

Childbirth

In the past, women would have delivered babies naturally at home with the aid of well-trained and experienced “nurses.” Homebirths have fallen out of favor and now “everyone goes to the hospital.”

Epidurals exist in Iraq but are not widely used. This is because many women “are still scared of having an injection in such a sensitive place.” This is a personal choice, and some refugee women from Iraq are receiving epidurals in the U.S.

In Iraq, a new mother is sent home with her baby after two or three hours, assuming that mom and baby are both well. If the mother undergoes an episiotomy procedure to help safe delivery, she and the baby will stay in the hospital for a few days until the episiotomy stitches can be removed.

The Iraqi American physicians who reviewed this article added that Cesarean delivery is not usually resisted if medically indicated, and that there is a cultural basis for breastfeeding in Iraq where it has been highly accepted and practiced for generations. However, during the period of sanctions, many women lacked nourishment and worried that their breast milk was inadequate and so use of formula increased. Some women may prolong breastfeeding until the child’s third or fourth year of life as a means of birth control.

Men often accompany women to appointments and procedures in Iraq. However, husbands are not allowed in the delivery room in Iraq. Women said that the American system of having the husband in the delivery room is preferred by Iraqi men and women. This allows the man to “have [the] same experience and know how hard [child birth] is…he sees all the pains and injections.” It also reduces the worry that can occur when waiting outside the delivery room.

A reviewer of this article who works in refugee resettlement notes that the presence of a male family member at a woman’s medical appointment makes it difficult for American health care providers to screen for domestic violence or for the woman to discuss health issues she would like to keep private. The tendency of a man to be present during a woman’s appointment might seem as infringing on her rights, even as it is noted that Iraqi women traditionally have had more equality in their society as compared with women of neighboring countries.

Pediatric Care

Kirkuk, Northern Iraq 9/13/03 IMC Project Al-Arafa Clinic. Dr. Mohammed Salih has worked at the clinic for years. The doctor uses the stethoscope to examine three year old Adra Nazi.

Pediatrics is its own specialty in Iraq, with many families choosing a doctor for their children and returning to that doctor as needed over time. Routine checkups are common for babies, particularly for immunizations. Then, when children reach school age, immunizations are received at school. Typically, in-between infancy and school age, well-child checks do not occur routinely, but young children go to the doctor when they are sick. Circumcision of boys is a personal choice, sometimes occurring in the first few days after birth, while some parents wait years. As children grow older they are taken to the doctor less frequently, though this depends on the parents. Parents accompany their child to the doctor until the child is married or unless living far away from the rest of the family. It is common that a relative or neighbor will take the child to the doctor if parents are unavailable. If a minor patient’s health care facility in the U.S. requires authorization to treat forms signed by parents, it would be helpful to inform parents of this in advance. It is unusual, but may occasionally happen, that teenagers seek a doctor’s care without their parents or a family member. In terms of interaction between the medical provider and the child, it is more common for discussions to be directed to the parents or mother. The provider “would address the mom because she is the one taking care of the child” and would likely not discuss health issues with the young child directly.

Preventive care is not common in Iraq, though this can depend on the individual. For simple illnesses, individuals generally only go to the doctor when feeling sick or in pain. However, if there is a family history of more serious diseases, such as diabetes or cancer, some individuals would go on their own accord for regular checkups. It is common for a doctor, in addition to examining a patient, to suggest that in-between doctor visits the patient could check herself as well, to become aware of any new changes that could be of concern. Screening tests are also unusual in Iraq, and “sometimes back in Iraq, we didn’t know if we have high cholesterol or diabetes.” One woman provided a theory about the lack of preventive care in Iraq, saying, “I think we are afraid to go to the doctor. We just don’t like it because if I go in for a checkup, maybe for my breasts, the doctor may say, ‘Oh, you have a mass, it may be cancerous.’ If you don’t go to the doctor and didn’t see it, then maybe there’s no problem. We are uneducated from this point. We don’t like to go, though it is not costly [financially].”

Female focus group participants mentioned that they are willing to receive regular checkups now that they are in the United States.

Hospitalization

In Iraq it is common for a family member to stay in the hospital with the patient. It is “better to stay with family” and personally “see the nurses and doctors are taking care” instead of sitting at home and worrying about their family member. Having family present also makes the patient more comfortable. However, only one family member would stay, not the entire family.

Dental Care

Dental care is usually only pursued if there is pain or another cause for concern. Because of the high cost of dental care in the U.S., it is “less expensive to return [to Iraq] to have dental work done.” Some refugees will take a vacation to Turkey, Georgia, or other countries to have dental work done.

Disability

Several Iraqi women shared that they were impressed by the treatment that people with disabilities receive in the U.S. They remarked that in Iraq, the disabled are not active members of society, wheelchairs are not available for those who need them, and people with disabilities typically do not work in a job outside the home. The Americans with Disabilities Act and efforts to include the disabled in the workforce are viewed by these women as a positive aspect of American life.

In the U.S. a disabled person may be rejected for SSI coverage if their disability would not render them ineligible to work. This can be difficult for a refugee applicant to understand. There may be barriers to employability in the U.S. for refugees who are disabled, such as not knowing sign language (for the deaf and hard of hearing) or having developmental effects from living in a sheltered environment in the home country.

Experience with Health Care in the U.S.

Positive Aspects

Iraqis generally believe that American doctors are well trained with high levels of skills and knowledge.

There is significant trust that the U.S. health care system is honest. “In the U.S. you are safe because with insurance there is another person tracking the validity and cost of treatment.” There are no worries about bribery either, because “when the justice system and education systems are good, it is usually not corrupt. We don’t worry about a bribe system here. Not at all. Because the law and law enforcement handle the system, there is no need to worry.”

Iraqi refugees favor the concept of preventive health care. “People are willing to go in for checkups regularly in the U.S. and we like this very much.” As such, preventive tests are also valued.

Focus group participants stated that they like the system common in the U.S. of receiving appointment reminders, both for doctor visits and routine screening, like mammograms.

An extensive report from Chicago’s Heartland Alliance Refugee Programs titled An Assessment of the Health of Iraqi Refugees in Chicago, tells of one refugee program clinic director who found that follow-up efforts kept the Iraqi refugees engaged in health care services (Giese, 2010).

A phone call from a child’s school if the child is sick or feeling unwell, a normal practice in the U.S., is seen as advantageous. In Iraq the school would only inform the parent if the child had an infectious disease like measles or mumps.

There is also appreciation for electronic medical records because in Iraq the doctor “may remember the person but [they] don’t have a record, especially because you can choose any doctor you want.” In Iraq, hospitals are not as well staffed as American hospitals with nurses and medical assistants, whose help is appreciated here in the U.S., particularly before and after surgery.

According to focus group participants, there have been no notable problems with medical interpretation. Most providers will use phone interpretation if necessary. There have been situations where interpreters were provided even when the individual patient did not feel it was necessary, such as when going to the doctor for simple medical tests. There is trust in interpreters in the U.S. because there is knowledge that “there are certain rules and that the interpreter is supposed to keep it secret.”

Negative Aspects

Wait Times

A long wait time for appointments and test results is a major frustration for Iraqis who are accustomed to same day results. When comparing the U.S. and Iraqi systems, one Iraqi stated that “we suffered mentally going through process [of accessing health care services] here while we don’t suffer from dead [wait] time in Iraq but from what was happening…physically.” This wait time is seen by most as a huge burden and a cause of anxiety, particularly with respect to receiving test results.

Use of antibiotics is widespread and common in Iraq. They are available in pharmacies without prescription. A big source of frustration for many Iraqi refugees is that “antibiotics are hard to get in the U.S. We’ve been using them for generations and cannot function without it.” American doctors will often prescribe pain medicine for temporary relief despite requests for antibiotics. Some Iraqi refugees say that this becomes an expensive process when the doctor must be visited several times for an illness that seemingly won’t get better without antibiotics. Iraqis “are not prescribed what they need and have to keep going back.” This has led some to rely on family members still living in Iraq to send antibiotics if American doctors will not prescribe them. The women in the focus group expressed an understanding that their children growing up in the U.S. will benefit from this system that prescribes fewer antibiotics and allows a child’s immune system to develop to resist infection. At the same time, they perceived that adults who routinely used antibiotics to recover from illness back home will suffer longer needlessly here, and will be unable to recover well enough from illnesses (“like flu”) at least in part because they are not given antibiotic treatment on which their bodies have come to depend.

Illustrative quotes about antibiotics from the focus groups:

“It is easy to get antibiotics in Iraq so most people have not built up their defense mechanism and so we need the antibiotics to get better.”

“We’re raised on antibiotics. It’s hard to take that away. Please listen to us!”

“Some people are weak, or females might need it. At the same time, doctors can be sued by patients, so they are more cautious about giving out medication. Doctors don’t have as much flexibility to give medication.”

“Doctors here will give medications for pain temporarily, but this doesn’t work because bodies are used to antibiotics from using them in Iraq.”

“To build up immune system, start with the baby and build defense mechanisms so he won’t need them every time. Older people have taken antibiotics many times and don’t have built up immune systems, so the U.S. system is not so good.”

“When I have dental things and can’t sleep with pain…I need medicine and antibiotics. You sometimes need antibiotics for the throat.”

“Doctors need to understand the cultural norms of antibiotics for Iraqis.”

Cost and other challenges of health care system

Medical costs and the insurance system are other significant sources of frustration. Visits to the emergency room were free in Iraq and doctor visits were inexpensive. These costs in the U.S. are particularly burdensome after refugee benefits expire. Because of the difficulty accessing health care when benefits expire, many “will go back to previous habits” and only seek medical care when they feel sick or have pain. Patients prescribed long courses of treatment may be unable to complete or adhere to the regimen once benefits expire and it becomes unaffordable. Not only is acquiring insurance difficult, but navigating the insurance system is also extremely frustrating for most Iraqi refugees. Some people find they unknowingly have a gap in coverage. It can be confusing (and may seem arbitrary) that there is coverage for some health care services but not others, especially when services are related to the same problem (e.g., an eye exam may be covered, but not corrective lenses or surgery until the condition worsens).

Other problems include having a difficult time explaining “to an American doctor what [medicine] you need” because of “confusion with British names used in Iraq.” Having to relay symptoms to multiple people during a doctor visit is commonly seen as an annoyance. There is also less follow up after the completion of a treatment to make sure the individual has responded to the treatment, whereas “it is typical in Iraq to go back [to the doctor] after taking medicine to make sure the problem is gone.”

Focus group participants shared disappointment that the typical duration of the office call in the U.S. is too short.

Health Beliefs, Attitudes, and Preferences

Typical Iraqi cooking is viewed as very healthy because it is “cooked well, uses lots of vegetables and it is lean. We eat a lot of fish and chicken, but not so much meat everyday.” Eating out is infrequent and most cooking is done at home. It is typical for individuals to adjust the food they eat as needed for health problems, and they will “eat the same food but cook it in a different way” such as by boiling. Participants mentioned that diabetics understand the need to limit rice, carbohydrates, and sugar. However this “depends on each person’s knowledge.” In general, those with more money eat better.

Though refugees in the focus groups reported that Iraqi cooking is healthy, one reviewer of this article noted that upon visiting many Iraqi refugee homes she observed foods prepared with large amounts of oil and butter, and believes that this may relate to high levels of chronic illness in the community.

Exercise

Exercise is not emphasized in Iraqi daily life. Instead it is a social activity and not generally regarded as important in maintaining good health. “As far as riding a bike, running in the street…we don’t do it. It is not proper for the head of the household to be seen doing this. It is kind of childish. It is fine in a sports club, but not in the street. Some enjoy tennis and swimming, but that is for sports. It even depends on if the person can afford a sports club.” Walking may be a more acceptable exercise option.

Medical Decision Making

Family plays a significant role in medical decision making. It is very common for the entire family to be involved in major health care decisions. There can be pressure from friends, extended family, and sometimes parents who provide suggestions and advice. However, the final decision is usually made within the immediate family. Women are typically able to make their own decisions, but “the husband asks about the side effects and implications of the procedures because it is his wife and it affects the entire household.” Other factors include financial implications, especially for expensive surgeries or medical treatment. In the U.S., most Iraqi refugees would prefer an Iraqi specialist practicing in the U.S. because they share the same culture.

In the Chicago report, a clinician interviewed said that some of the Iraqi refugee patients at the health center were seeking the advice of Iraqi doctors from their communities after receiving services at the health center. Sometimes the Iraqi doctor’s advice would be followed instead and the person would not adhere to directions given at the health center, particularly with respect to following INH treatment for latent TB (Giese, 2010). Participants in one of our Seattle-area focus groups were asked about this. They reported that this would be unusual, due to the high level of trust in American health care.

Qualities of a Good Doctor

It is important for doctors in the U.S. to smile and listen to all of the individual’s complaints, then “address them one by one.” Put another way, the Iraqis interviewed agreed that “we prefer that the doctor listen to us, what we say and the pain we’ve been through” instead of trying to solve one problem at a time and then we don’t get to all the problems.” It is also important for the doctor to present all possible options with the associated costs, though many Iraqis prefer that the doctor identifies the best treatment. One refugee noted, “If a doctor can’t make a decision or hesitates, they are not doing things well because they [should] have the expertise to make determination.” Another Iraqi refugee acknowledged the differences in the U.S. system, noting, “the system where you get all the options is part of American medicine. At the same time, it makes me paranoid when the doctor can’t make the decision. The doctor should have the last choice.” Put another way, if the doctor gives various options for treatment and then asks the patient what he/she thinks in order to determine the course of action, the doctor risks losing respect in the eyes of the patient.

Health Education Needs

Understanding the insurance system is one of the major areas of need for Iraqi refugees living in the U.S. Many have found it frustrating and confusing, resulting in significant problems if they lose coverage after initial refugee benefits expire. This is closely associated with the frustration around unemployment. Many of the Iraqi refugees are highly educated and have good English language skills, yet have difficulty continuing in their professions upon arrival to the U.S. This can impact mental health, as jobs are seen as important to “keep the mind activated” and a desire for “something to do with energy.”

A need for health information in Arabic was expressed: “DSHS doesn’t have health information in the Arabic language.”

According to informants in the Chicago report, perceptions regarding the biggest health care needs include chronic disease awareness and prevention, education about diabetes, obesity, high blood pressure and high cholesterol. Less critical topics included nutrition, sanitation and domestic hygiene (Giese, 2010).

In Iraq, the availability of health information varied between rural and urban areas. The Minister of Health “sends out teams to disseminate health knowledge,” especially in rural areas. In the city this was frequently done via newspapers and TV. In urban areas, many relied on word of mouth when choosing a doctor.

Locally, in the Seattle area, the lack of a cohesive Iraqi community has prevented refugees from spreading health care information among themselves. Many participants talked about how eager they are for opportunities to gather with other local refugees to socialize and share information. Additionally, they identified meeting as a group and pamphlets as good ways of obtaining health information. It is preferred if this information is in Arabic, though English is adequate if the pamphlet is short. Pictures are also appreciated.

Informants for the report about refugees in Chicago echoed the desire for opportunities to socialize, as was also expressed by Iraqis at a community meeting in Seattle. Undoubtedly, this would enhance social support, cohesiveness and positive impact on overall health (Giese, 2010).

Traditional Medical Practices

There are people who specialize in traditional medical practices or herbal remedies in Iraq. However traditional medicines are not commonly used and would be used primarily for the hair or for cosmetic reasons, not in place of a doctor. Religion is important, and most “believe God can heal someone.” However, this “doesn’t mean going to a religion man.” Instead, many will “stay home and pray.” There is still a great trust in doctors and medicine and any traditional and/or religious practices would likely be in addition to other medical care.

In Iraq, there is intense stigma associated with mental illness and there is a general belief that it is incurable. Mental health hospitals are places where political dissidents are sent. Mental health care was notone of the more successful branches of medicine developed in Iraq even prior to sanctions and war. Treatment for mental problems would be sought only in cases of severe mental illness. In Iraq, if someone were to seek mental health treatment for issues like depression or trauma “people would think he is not normal.” Counseling is not common if existent at all. “There are no doctors for sadness in Iraq.” Instead individuals rely on family and friends for help. One Iraqi refugee hypothesized, “Maybe because we are always having problems and wars, any simple problem would not seem like more.” There is also concern that “the doctor would think differently of you if seeking counseling.”

Iraqi refugees attending a Seattle-area workshop in spring 2010 described how people in their community might typically talk about coping emotionally:

“Many people had terrible experiences and it can help to talk and realize others had worse experiences.”

“You can talk to people who struggle, but if they can’t find strength to help themselves, then you can’t help either…it is up to Allah.”

“It is better not to touch the story, but to destroy [the] old. Forget it. Just focus on the future, rebuild.”

Even though stigma about mental illness is so intense in Iraq, the refugees in the focus groups suggested people might be more open to the idea of mental health counseling once they are in the U.S. because “here society is different. Some participants said that if an American health care provider asked about suicidal thoughts it would not be viewed as offensive or seen as questioning an individual’s faith. Instead “It’s like someone hearing you and asking what’s going on.” Focus group participants suggested that because there is not a strong network of friends and family in the U.S., seeking help from counseling professionals might be viewed by some refugees as being more acceptable. However, they stated that they still would not admit widely that they were accepting or seeking mental health help. Only spouses or parents would be informed, if anyone. A mental health care provider who cares for Iraqi refugee patients in the Seattle area says she has observed that many people think “I am the only one who feels this way” (i.e., that what happened in the past, and the pressures now in the U.S. are ‘squeezing my heart and mind’ very hard). When asked in a large discussion group with fellow Iraqi refugees, participants did not admit knowing people in the community who are having extreme sadness and worry. They did freely acknowledge knowing people who are having headaches and other symptoms.

Readers are cautioned not to generalize from this small sample that all Iraqi refugees will be open to counseling.

The Cultural Orientation Resource Center's Enhanced Refugee Backgrounder Refugees from Iraq: Their History, Culture and Background Experiences, states that some Iraqi refugees who have experienced trauma "may want to explore their spiritual needs; some may have strengthened or forsaken their faith due to the trauma." (Ghareeb, Ranard, & Tutunji, 2008).

Mind-Body Connection

Iraqis we spoke with are familiar with the concept that stress can cause physical problems. However, most would not go to a mental health professional but would try to fix the source of stress on their own. One Iraqi stated this clearly, saying, “The psychological issues affect the human body. Through all the struggles in our country, this affects our mentality and hurts blood pressure, causes heart attacks, and diabetes. We totally understand this. For psychological doctors in Iraq, they deal with crazy people, but it is different here. Doctors here go through the mental issues to understand the physical.”

Drugs/Alcohol

Drug and alcohol abuse were not identified as a problem among Iraqi refugees. Under previous governments, people who were associated with drugs would be executed. However, borders are now more open and drugs are beginning to affect people in Iraq.

Elders

Nursing homes are not common in Iraq and are limited to serving those individuals without friends or family who would otherwise help them. When elder care is needed, often a nurse will visit the patient in the home. In Iraq “kids always check up on parents and love them and serve them and if they don’t have retirement salary, they would help their family.”

From the Refugees: What They Would Like Americans and American Health Care Providers to Know

They’re grateful to be in the U.S. & want to learn about the U.S. and American culture

Iraqi refugees expressed interest in learning about Americans and the United States in terms of culture, society, and history. They described feeling relief and gratitude for being brought to safety, even while being concerned that it is so very difficult to find employment here.

It is also very important to the refugees that they are identified and appreciated as being from a country and society unique from its neighboring countries. Refugees have observed that many Americans have a misconception that Iraq is an undeveloped country. A refugee who spoke at a workshop in 2010 described, “We need to get the word out that we are people with skills who can give value to your society. Give us a chance.” Another person added that he would like to educate Americans about the Iraqi community and culture, especially clarifying how modern they are, that they come from “the cradle of civilization” because of misperceptions that they’re from “the stone age.” Some Iraqi refugees said they expected that since the U.S. was inviting them to come, that the American people would know their value and welcome their contributions. They would like to share their background, culture, and unique traditions with Americans. “We are refugees because we ran away. We want people to listen to us.”

Their recommendations specific to health care

Learn a little about Iraq and its location in the Middle East.” Participants described encounters with American medical providers who confused their country of origin with Iran or other countries in the Middle East. For example, a provider told the patient, “Iran – Iraq – it’s the same country.” Making that kind of mistake risks diminishing the respect and confidence the patient has in the doctor. “I want to be considered a human with my own culture. I want American doctors to be sensitive to that.”

Acknowledge cultural norms and traits, such as knowing that Muslims are prohibited from eating pork.

It is important that health care providers smile when interacting with Iraqi refugees. “Smiling is part of customer service.”

“Ask about family and know entire situation.” Friendly discussion increases the patient’s confidence in the doctor and “it builds trust so we will follow doctor’s directions directly.”

“Understand the cultural norms of antibiotics.” Understand that there is prevalent use of antibiotics in Iraq.

”If you listen well, the patient will know that you understood the problem and will provide the proper care.”

Recommendations for Working with Iraqis in Health Care and Social Service Settings

The following recommendations come from resettlement coordinators, a mental health professional, and the Iraqi American physicians who helped review this article.

Recommendations for health care personnel:

Familiarize yourself with general knowledge of Iraq. Iraqis are proud of their heritage. Do not confuse Iraq and Iran.

When doing initial intake at health care facility, ask the patient about his or her employment in Iraq, educational background, and religion. For example, knowing that the patient was a professional in Iraq and from a higher socioeconomic standing will help the provider understand that the patient was likely not expecting to work a low wage job or even be unemployed, both of which are significant sources of stress.

When a patient or family is new to the clinic, if possible, have staff explain how the primary care system works, including: annual checkups, well-child care, preventive care, obtaining medications, and the typical length of the office call. Explain that a limited number of health concerns and acute needs are usually addressed in a single appointment, and that additional concerns can be dealt with in follow-up appointments. Explain that referrals to specialists generally take some time to schedule.

Iraqi women generally prefer to receive care from a female provider. When the provider is male, have female staff present when performing physical exams.

Address the patient formally, using Mr., Mrs., or Miss. Do not use first names.

If the husband is in the room with his wife who is the patient, be sure to acknowledge his presence when you are speaking.

Upon starting the medical encounter, a smile, brief pleasantries, and a little small talk before launching into medical issues will help build rapport. Spending a little time on small-talk or pleasantries is part of the culture in Iraq. Ask some questions, such as: Which part of Iraq do you come from? I know there is a rich history there.

Because Iraqi patients may wish to list all physical complaints at the beginning of the office visit, explain that it is best to prioritize their complaints, starting with the most urgent concerns. Clarify that a follow-up appointment can be made to address problems not addressed in this visit. Make sure that the patient doesn’t feel shortchanged due to being a refugee.

Have clinic staff perform follow-up phone calls to help keep patients engaged in health care services. This will help increase the likelihood of patient follow-up.

It is important that patients feel like their providers are listening attentively. This will help build trust and confidence.

Iraqi patients may appreciate a more decisive approach and may expect the physician’s opinion about treatment options. Tell the patient what you think is the best option. Not doing this may give the impression that you don’t know what you are doing.

Provide health education about antibiotics, especially when they are not indicated. Understand the culture around antibiotic use in Iraq.

Provide dietary counseling to help combat high levels of chronic illness, especially to help prevent or treat diabetes.

As part of well-child care, explain to parents that behavior management and discipline may be different in the U.S. than in Iraq. Educate about behavior management and discipline alternatives to physical punishment.

In Iraq it is common for a neighbor or family member to take a child to the doctor if parents are unavailable. If a minor patient’s health care facility in the U.S. requires authorization to treat forms signed by parents, it would be helpful to inform parents of this in advance.

Compliment women who choose to breastfeed as a means of encouragement and to reinforce that cultural norm. If a woman is breastfeeding for a prolonged period of time, inquire about her birth control needs and whether she is supplementing with formula.

Some Iraqis experience a high number of somatic complaints that are characteristic of mental health problems such as PTSD, anxiety or depression. When working with Iraqis, it is important to avoid using the term “mental health.” One alternative is to use symptoms rather than jargon. For example, “You are having trouble sleeping at night and you cry every day.” Rather than, “You seem depressed.” Or, “You have bad nightmares and think about what happened to you all the time.” Instead of, “You have PTSD.” Then talk about the treatment plan in terms of how it might alleviate symptoms. If it is not possible to avoid saying “mental health,” the following explanation may help: “'Mental health' in the United States means something different than in many parts of the world. I know in many places 'mental health' means the same as 'crazy.' Here, mental health refers to a range of symptoms from not sleeping well, to having nightmares, to feeling like there are too many thoughts racing in your head, to crying a lot. Because refugees have been through so many bad things, and because adjusting to life in the U.S. is hard, sometimes they need extra support. That is what we do here. This is why we would like to refer you to____. We try to find out what is happening in your life and how we can help."

If a physician refers the patient for counseling, it is recommended that the physician’s office make the referral instead of simply giving the contact information to the patient. This will increase the likelihood that the patient will go.

Understand that survivors of torture or extreme trauma will have more needs and require more help than other refugees to rebuild their lives. They will likely require more time and encouragement to access the needed medical, legal, mental health, employment, educational, and social services.

Incentives such as public transportation passes and opportunities to socialize with others (thereby improving social support and bonding within the community) can be helpful to encourage participation in health related programs (Giese, 2010). Keep in mind that there is great diversity among Iraqis and understand there may be resistance to mixing with others outside socioeconomic, religious or political lines.

Some people may be more forceful regarding their needs, possibly seeming pushy or demanding. Be patient and explain the system as it works here. Understand that in Iraq’s resource-poor health care system, being loud or insistent could help get what was needed. In the U.S. we might say “it’s the squeaky wheel that gets the grease.” In Iraq, people may have had to resort to bribery or personal connections in order to get what they needed.

Exercise is not emphasized in Iraqi daily life. Instead it is considered a social activity and not generally regarded as important in maintaining good health. Sports, tennis and swimming are typically done at sports clubs. Running outdoors is considered inappropriate. Walking, however, may be a more acceptable exercise option.

Recommendations for resettlement and social service agency staff:

Encourage refugees to bring medical records from Iraq to the U.S. if suffering from disability or serious or chronic medical condition.

Help refugees set short term and long term goals soon after arrival. This can help with managing expectations, as well as developing a mindset that things may take time but will not always be as hard as they are initially.

Bargaining over prices was common in Iraq. There have been reports of refugees here trying to bargain over rent costs with landlords. It will be helpful if you can explain the system in the U.S.

Additional Resources

CDC health profile with key health and cultural information for groups resettling in the US. Contains information from World Health Org (WHO), International Organization for Migration (IOM), the Office of the United Nations High Commissioner for Refugees (UNHCR), and the US Department of State.

Bridging Refugee Youth & Children’s Services (BRYCS) has compiled a list of highlighted resources about Iraqi refugees and their children. Among the resources are a bibliography of selected references on Arab Americans, information about Arab youth in the U.S. and tools for working with them, information about Iraqi Kurds and Christians, profiles of individual refugees who have resettled in the U.S., videos about refugees, and reports on the resettlement experience.

This newsletter from the National Center for Refugee Employment and Self-sufficiency highlights a program in Detroit to improve employment services for Iraqi refugees. Factors that affect employability are covered in-depth. March, 2008.

Listen to the remarkable story of one Iraqi refugee, Nazar Al Taee, who was injured in a mortar attack while working as an interpreter for the U.S. Army. He has become a U.S. citizen and has enlisted in the U.S. Army to serve in Iraq.

This report from the Gulf Coast Jewish Family and Community Services provides some historical timelines, brief description of common methods of torture, and synopses of current conditions and pertinent issues.

Health Education Resources in Arabic

MedlinePlus is the National Institutes of Health's web site for patients. Produced by the National Library of Medicine, it has information about diseases, conditions, and wellness issues in many languages. It contains hundreds of documents and some multimedia tutorials in Arabic, many drawing from sites listed below.

Health education materials on a wide range of topics in a number of languages and a variety of formats. Materials are developed with attention paid to the issues of literacy, health-literacy, illness, aging, disability and language.

Health Information Translations is a collaborative initiative to improve health education for limited English proficiency patients, by leveraging the combined skills and experience of three of Central Ohio's largest health care organizations in the production of translated patient education materials.

Centers for Disease Control and Prevention. Health of Resettled Iraqi Refugees – San Diego County, California, October 2007-September 2009. Morbidity and Mortality Weekly Report, December 17, 2010. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5949a2.htm